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Your name:
Your Kaiser medical record number:
1. How would you describe your health at the present?
Please tick one answer
Very good
Good
Fair
Poor
Very poor
2. How much do you think your bladder problem affects your life?
Please tick one answer
Not at all
A little
Moderately
A lot
Please turn the page
THE KING’S HEALTH QUESTIONNAIRE
Below are some daily activities that can be affected by bladder problems.
How much does your bladder problem affect you?
We would like you to answer every question. Simply tick the box that applies to you
- ROLE LIMITATIONS Not at all Slightly Moderately A lot
A. Does your bladder problem affect your household tasks? (cleaning, shopping etc)
B. Does your bladder problem affect your job, or your normal daily activities outside the home?
1 2 3 4
- PHYSICAL/SOCIAL LIMITATION Not at all Slightly Moderately A lot
A Does your bladder problem affect your physical activities (e.g. going for a walk, running, sport, gym etc)?
B. Does your bladder problem affect your ability to travel?
C. Does your bladder problem limit your social life?
D. Does your bladder problem limit your ability to see and visit friends?
0 1 2 3 4
- PERSONAL RELATIONSHIPS Not Not at all Slightly Moderately A lot Applicable
A. Does your bladder problem affect your relationship with your partner?
B. Does your bladder problem affect your sex life?
C. Does your bladder problem affect your family life?
We would like to know what your bladder problems are and how much
they affect you? From the list below choose only those problems that
you have at present. Leave out those that don’t apply to you.
How much do they affect you? FREQUENCY: going to the toilet very often
- A little 2.Moderately 3. A lot
NOCTURIA: getting up at night to pass urine
- A little 2.Moderately 3. A lot
URGENCY: a strong and difficult to control desire to pass urine
- A little 2.Moderately 3. A lot
URGE INCONTINENCE: urinary leakage associated with a strong desire to pass urine
- A little 2.Moderately 3. A lot
STRESS INCONTINENCE: urinary leakage with physical activity eg. coughing, running
- A little 2.Moderately 3. A lot
NOCTURNAL ENURESIS: wetting the bed at night
- A little 2.Moderately 3. A lot
INTERCOURSE INCONTINENCE: urinary leakage with sexual intercourse
- A little 2.Moderately 3. A lot
WATERWORKS INFECTIONS
- A little 2.Moderately 3. A lot
BLADDER PAIN
- A little 2.Moderately 3. A lot
Thank You For Your Time
